Form NA403 "Notice of Action - for Resource Families, Including Homes Certified by a Foster Family Agency, County Approved Relative Homes, Non-relative Extended Family Members, Foster Family Homes, Non-related Legal Guardians, Intensive Treatment Foster Care and/or Intensive Services Foster Care, Group Homes and Short-Term Residential Therapeutic Programs" - California

What Is Form NA403?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2021;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form NA403 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form NA403 "Notice of Action - for Resource Families, Including Homes Certified by a Foster Family Agency, County Approved Relative Homes, Non-relative Extended Family Members, Foster Family Homes, Non-related Legal Guardians, Intensive Treatment Foster Care and/or Intensive Services Foster Care, Group Homes and Short-Term Residential Therapeutic Programs" - California

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NOTICE OF ACTION - APPROVAL,
COUNTY OF
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CHANGE OR DISCONTINUED
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Notice Date:
For Resource Families, including homes certified by a
___________________________________________________________
Foster Family Agency, County Approved Relative Homes,
Case Name:
___________________________________________________________
Non-Relative Extended Family Members, Foster Family
Case Number
:___________________________________________________________
Homes, Non-Related Legal Guardians, Intensive Treatment
Worker Name
:___________________________________________________________
Foster Care and/or Intensive Services Foster Care, Group
Worker Number:
___________________________________________________________
Homes and Short-Term Residential Therapeutic Programs
Telephone:
___________________________________________________________
Address:
___________________________________________________________
(ADDRESSEE)
___________________________________________________________
___________________________________________________________
Questions? Ask your Worker.
State Hearing: You are no longer eligible to appeal
the disqualification action in a State Hearing. If you
disagree with the amount you owe, and the amount
you owe was not part of the hearing decision, you
may ask for a State Hearing by filling out the back
of this form and returning it by ______________.
APPROVAL
… The County has approved your Foster Care aid.
As of _____________, the county is Approving your
Foster Care aid of $ _____________ per month.
This aid is for: _______________________________.
CHANGE
As of _____________, the county is Changing your
Foster Care aid from $ __________ to $ __________.
This aid is for: _______________________________.
Here’s why: Your rate is based on a level of care
determination as defined in AB 403 and WIC section
11461.
… Your case had a rate increase.
… Your case had a rate decrease.
… Your case had no change in rate.
… Your case has been issued an Infant
Supplemental Payment.
… Your case has been issued a Supplemental Care
Increment.
… The child has countable income.
__________________ for ______________________
of $ _____________ is effective ________________.
This is counted as __________________________
income in the Foster Care budget calculation.
… Other: __________________________________
… Due to funding requirements, you may receive
multiple checks for this benefit month. The sum
of these checks will be equal to the amount listed
above.
Page 1 of 3
NA 403 (9/21)
NOTICE OF ACTION - APPROVAL,
COUNTY OF
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CHANGE OR DISCONTINUED
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Notice Date:
For Resource Families, including homes certified by a
___________________________________________________________
Foster Family Agency, County Approved Relative Homes,
Case Name:
___________________________________________________________
Non-Relative Extended Family Members, Foster Family
Case Number
:___________________________________________________________
Homes, Non-Related Legal Guardians, Intensive Treatment
Worker Name
:___________________________________________________________
Foster Care and/or Intensive Services Foster Care, Group
Worker Number:
___________________________________________________________
Homes and Short-Term Residential Therapeutic Programs
Telephone:
___________________________________________________________
Address:
___________________________________________________________
(ADDRESSEE)
___________________________________________________________
___________________________________________________________
Questions? Ask your Worker.
State Hearing: You are no longer eligible to appeal
the disqualification action in a State Hearing. If you
disagree with the amount you owe, and the amount
you owe was not part of the hearing decision, you
may ask for a State Hearing by filling out the back
of this form and returning it by ______________.
APPROVAL
… The County has approved your Foster Care aid.
As of _____________, the county is Approving your
Foster Care aid of $ _____________ per month.
This aid is for: _______________________________.
CHANGE
As of _____________, the county is Changing your
Foster Care aid from $ __________ to $ __________.
This aid is for: _______________________________.
Here’s why: Your rate is based on a level of care
determination as defined in AB 403 and WIC section
11461.
… Your case had a rate increase.
… Your case had a rate decrease.
… Your case had no change in rate.
… Your case has been issued an Infant
Supplemental Payment.
… Your case has been issued a Supplemental Care
Increment.
… The child has countable income.
__________________ for ______________________
of $ _____________ is effective ________________.
This is counted as __________________________
income in the Foster Care budget calculation.
… Other: __________________________________
… Due to funding requirements, you may receive
multiple checks for this benefit month. The sum
of these checks will be equal to the amount listed
above.
Page 1 of 3
NA 403 (9/21)
NOTICE OF ACTION - APPROVAL,
COUNTY OF
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CHANGE OR DISCONTINUED
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Notice Date:
For Resource Families, including homes certified by a
___________________________________________________________
Foster Family Agency, County Approved Relative Homes,
Case Name:
___________________________________________________________
Non-Relative Extended Family Members, Foster Family
Case Number
:___________________________________________________________
Homes, Non-Related Legal Guardians, Intensive Treatment
Worker Name
:___________________________________________________________
Foster Care and/or Intensive Services Foster Care, Group
Worker Number:
___________________________________________________________
Homes and Short-Term Residential Therapeutic Programs
Telephone:
___________________________________________________________
Address:
___________________________________________________________
(ADDRESSEE)
___________________________________________________________
___________________________________________________________
Questions? Ask your Worker.
State Hearing: You are no longer eligible to appeal
the disqualification action in a State Hearing. If you
disagree with the amount you owe, and the amount
you owe was not part of the hearing decision, you
may ask for a State Hearing by filling out the back
of this form and returning it by ______________.
DISCONTINUED
… Your case has been discontinued.
As of ____________, the county is Discontinuing
your Foster Care aid of $ _____________ per month.
Here’s why:
… You are no longer providing foster care
for: _____________________________________
… The child’s dependency case has been dismissed.
… He/she is no longer living in your home/facility.
The County will stop paying for Foster Care from
the day the child leaves your home/facility. He/she
no longer meets the age rules.
… The youth is at least 18 years of age and does not
qualify for extended foster care.
… The youth is at least 21 years of age.
… The child has too much income.
… The child has too much property. See attached
page. If the County figured that the child’s vehicle
or other property was worth more than you think
it’s worth, you can give the County proof that it is
worth less. Ask the County how. If you can prove it
is worth less the child may get Foster Care aid.
… The legal guardianship was terminated.
… You moved out of the State of California.
… You did not return your completed redetermination
paperwork.
… Other:___________________________________
Page 2 of 3
NA 403 (9/21)
TO ASK FOR A HEARING:
YOUR HEARING RIGHTS
Fill out this page.
You have the right to ask for a hearing if you disagree with any
Make a copy of the front and back of this page for your records.
county action. You have only 90 days to ask for a hearing.
If you ask, your worker will get you a copy of this page.
The 90 days started the day after the county gave or mailed
Send or take this page to:
you this notice. If you have good cause as to why you were
not able to file for a hearing within the 90 days, you may still
file for a hearing. If you provide good cause, a hearing may
still be scheduled.
OR
If you ask for a hearing before an action on Cash Aid,
Call toll free: 1-800-952-5253 or for hearing or speech impaired
Medi-Cal, CalFresh, or Child Care takes place:
who use TDD, 1-800-952-8349.
Your Cash Aid or Medi-Cal will stay the same while you wait for a
To Get Help: You can ask about your hearing rights or for a legal
hearing.
aid referral at the toll-free state phone numbers listed above. You
may get free legal help at your local legal aid or welfare rights office.
Your Child Care Services may stay the same while you wait for a
hearing.
Your CalFresh benefits will stay the same until the hearing or the
end of your certification period, whichever is earlier.
If the hearing decision says we are right, you will owe us for any
If you do not want to go to the hearing alone, you can bring a
extra Cash Aid, CalFresh or Child Care Services you got. To let us
friend or someone with you.
lower or stop your benefits before the hearing, check below:
HEARING REQUEST
Yes, lower or stop:
Cash Aid
CalFresh
n
n
I want a hearing due to an action by the Welfare Department
Child Care
n
of ________________________________ County about my:
While You Wait for a Hearing Decision for:
Cash Aid
CalFresh
Medi-Cal
n
n
n
Welfare to Work:
Other (list) ___________________________________________
n
You do not have to take part in the activities.
Here’s Why: _____________________________________________
You may receive child care payments for employment and for activities
approved by the county before this notice.
________________________________________________________
If we told you your other supportive services payments will stop, you
________________________________________________________
will not get any more payments, even if you go to your activity.
If we told you we will pay your other supportive services, they will be
________________________________________________________
paid in the amount and in the way we told you in this notice.
________________________________________________________
To get those supportive services, you must go to the activity the
county told you to attend.
________________________________________________________
If the amount of supportive services the county pays while you
If you need more space, check here and add a page.
wait for a hearing decision is not enough to allow you to
n
participate, you can stop going to the activity.
I need the state to provide me with an interpreter at no cost to me.
n
(A relative or friend cannot interpret for you at the hearing.)
Cal-Learn:
My language or dialect is: ____________________________
You cannot participate in the Cal-Learn Program if we told you
we cannot serve you.
NAME OF PERSON WHOSE BENEFITS WERE DENIED, CHANGED OR STOPPED
We will only pay for Cal-Learn supportive services for an
BIRTH DATE
PHONE NUMBER
approved activity.
STREET ADDRESS
OTHER INFORMATION
CITY
STATE
ZIP CODE
Medi-Cal Managed Care Plan Members: The action on this notice may stop
you from getting services from your managed care health plan. You may wish to
SIGNATURE
DATE
contact your health plan membership services if you have questions.
Child and/or Medical Support:
The local child support agency will help
NAME OF PERSON COMPLETING THIS FORM
PHONE NUMBER
collect support at no cost even if you are not on cash aid. If they now collect
support for you, they will keep doing so unless you tell them in writing to stop.
I want the person named below to represent me at this
n
They will send you current support money collected but will keep past due
hearing. I give my permission for this person to see my
money collected that is owed to the county.
records or go to the hearing for me. (This person can be a
Family Planning: Your welfare office will give you information when you ask
friend or relative but cannot interpret for you.)
for it.
NAME
PHONE NUMBER
Hearing File: If you ask for a hearing, the State Hearing Division will set up a
file. You have the right to see this file before your hearing and to get a copy of
STREET ADDRESS
the county’s written position on your case at least two days before the hearing.
The state may give your hearing file to the Welfare Department and the U.S.
CITY
STATE
ZIP CODE
Departments of Health and Human Services and Agriculture.
(W&I Code
Sections 10850 and 10950.)
NA BACK 9 (REPLACES NA BACK 8 AND EP 5) (REVISED 4/2013) - REQUIRED FORM - NO SUBSTITUTE PERMITTED
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